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288 Distúrb Comun, São Paulo, 30(2): 288-297, junho, 2018
Breastfeeding practice among
women with childcare center
in workplace
Práticas de amamentação entre mulheres
trabalhadoras com creche no local de trabalho
Práctica de lactancia materna entre
mujeres con centro de cuidado infantil
en el lugar de trabajo
Thais Rosa dos Santos*
Luciana Tavares Sebastião**
Gabriela dos Santos Buccini*** Abstract
Objective: To describe and analyze exclusive breastfeeding practice among working women with a
Childcare Center in the workplace. Methods: The study was conducted in a Childcare Center linked to an
Educational Institution. A questionnaire was used to collect data. Cox analysis was used to determine the factors associated with the duration of exclusive breastfeeding. Results: The sample involved 46 mothers
of children with an average age of 2.6 years. Approximately half of the mothers were 35 years or more, and 73.9% were health professionals. Exclusive breastfeeding prevalence at six months was 15.2%. All mothers had 120 days of maternity leave and only 10.8% enjoyed breastfeeding breaks. The low birth weight, type of follow-up health service, maternal age and child’s age of bottle-feeding introduction were factors associated with duration of exclusive breastfeeding. Conclusion: Maternity leave has been
enjoyed in accordance with the law, although other important rights for the protection of breastfeeding were not. Factors associated with the duration of exclusive breastfeeding among working women with Childcare in the workplace are complex and go beyond compliance with labor laws.
*Universidade de São Paulo, Bauru, SP, Brazil **Unesp - Campus de Marília, Marília, SP, Brazil ***Yale University, New Haven, Connecticut, USA
Authors’ contributions:
TRS contributed to the study design and performed data collection. She also organized the sections of the paper and reviewed the final version.
LTS contributed to the study design and supervised data collection. She also reviewed the final version of the paper. GSB contributed to the study design and conducted the analyzes. She also reviewed the final version of the paper.
Correspondence address: Luciana Tavares Sebastião luts@marilia.unesp.br Received: 13/07/2017
Accepted: 27/04/2018
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Keywords: Women Working; Breastfeeding; Child Health; Speech, Language and Hearing Sciences.
Resumo
Objetivo: Descrever e analisar as práticas de aleitamento materno exclusivo entre mulheres
trabalhadoras com creche no local de trabalho. Métodos: O estudo foi realizado em um Centro de
Convivência Infantil, vinculado a uma Instituição de Ensino Superior. Para coleta de dados utilizou-se um questionário estruturado. Realizou-utilizou-se análiutilizou-se múltipla de Cox para determinação dos fatores associados à duração do aleitamento materno exclusivo. Resultados: Participaram da pesquisa 46 mães
de crianças com idade média de 2,6 anos. Aproximadamente metade das mães tinham 35 anos ou mais e 73,9% eram profissionais de saúde. A prevalência de aleitamento materno exclusivo até os seis meses foi 15,2%. Todas as mães tiveram 120 dias de licença maternidade e apenas 10,8% usufruíram o direito de pausas para amamentar. Baixo peso ao nascer, tipo de serviço de saúde em que a criança realizava acompanhamento, idade da mãe e a idade de introdução da mamadeira foram fatores associados à duração do aleitamento materno exclusivo. Conclusão: Apesar da licença de maternidade ter sido gozada de
acordo com o previsto em lei, outros direitos trabalhistas para a proteção da amamentação não foram fruídos. Os fatores associados à duração do aleitamento materno exclusivo entre mulheres trabalhadoras com creche no local de trabalho são complexos e vão além do cumprimento de leis trabalhistas.
Palavras-chave: Trabalho Feminino; Saúde da Criança; Aleitamento Materno; Fonoaudiologia. Resumen
Objetivo: Describir y analizar las prácticas de la lactancia materna exclusiva entre las mujeres que
trabajan y que tienen una guardería infantil en el lugar de trabajo. Métodos: El estudio se realizó en
un Centro de Convivio Infantil vinculado a una Institución Universitaria. Para recompilar los datos se utilizó un cuestionario estructurado. Se realizó el análisis múltiple de Cox para determinar los factores asociados con la duración de la lactancia materna exclusiva. Resultados: Participaron de la investigación
46 madres del niños con edad media de 2,6 años. Aproximadamente la mitad de las madres tenia 35 años o más, y 73,9% eran profesionales de la salud. La prevalencia de la lactancia materna exclusiva hasta los seis meses fue del 15,2%. Todas las madres han disfrutado de 120 días de licencia de maternidad y sólo el 10,8% han disfrutado de pausas para la lactancia. El bajo peso al nacer, el tipo de servicios de salud de vigilancia del niño, la edad materna y la edad de introducción de la alimentación con biberón fueran factores que se asociaron con la duración de la lactancia materna exclusiva. Conclusión: Aunque
la licencia de maternidad ha sido disfrutada de conformidad con la ley, otros derechos importantes para la protección de la lactancia materna no lo fueron. Los factores asociados con la duración de la lactancia materna exclusiva entre las mujeres que trabajan con guardería infantil en el lugar de trabajo son complejas y van más allá del cumplimiento de las leyes laborales.
Palabras clave: Trabajo femenino; Lactancia materna; Salud Infantil; Fonoaudiologia.
Introduction
The benefits of exclusive breastfeeding prac-tice (EBF) in the first six months of the child’s life are well covered by the literature1,2,3,4,5. However,
breastfeeding indicators in Brazil show that early EBF interruption remains a public health prob-lem6,7.
There are multiple and complex factors that determine the EBF interruption, ranging from indi-vidual (related to mothers and infants), contextual
(socioeconomic, health care, political, marketing) and even cultural factors8. The mother’s return to
work stands out among these factors. A study con-ducted in the USA showed that the mother’s return to work was the main cause of early weaning, ac-counting for 58% of all cases9. Similar results were
obtained in studies conducted in Belém/PA, Brazil, and also in four communities in Guatemala10,11.
Legal provisions have been drafter in Brazil in order to protect the EBF continuity with respect to mother’s return to work. The Brazilian Federal
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whose mothers didn’t work at a HEI at the time ofthe child’s birth.
The data collection tool was elaborated based on the questionnaire used in the “National Survey on Food Practices in the First Year of Life”6.
Ad-justments were made according to the specificity of the sample involved in the study and a pre-test step was performed using the CCI questionnaire in another HEI in the same city in order to ensure the reliability of the instrument. The questionnaire covered BF-related issues, as well as knowledge and enjoyment of the mother’s labor rights and it had been submitted to be completed at home with an explanatory letter and the Free and Informed Consent Form (FICF).
The BF duration was regarded as the endpoint for data analysis. The age of the child at the time of the BFE interruption was used as a variable to estimate the BFE duration. The study used the BFE definition by the WHO16.
Data related to the following factors were analyzed: (1) mother - age (<35 years old/ ≥35 years old), education level (high school, vocational, higher), primiparity (yes/no); (2) child - gender (male/female), low weight at birth (yes/no), age at introduction at CCI (£6 months/ >6 months), age at introduction of water, tea, juice and other milk (months), pacifier use (yes/no), age at pacifier in-troduction (months), bottle-feeding use (yes/no), age at bottle-feeding introduction (months); (3) delivery assistance and outpatient follow-up - birth at Amigo da Criança Hospital (yes/no), Breast-feeding in the first hour of life (yes/no), type of delivery (Natural birth - forceps delivery/cesarean birth), health monitoring service (Private - Health Insurance/Public) and (4) enjoyment of labor rights - maternity leave (yes/no), breastfeeding breaks (yes/no).
Initially, a descriptive analysis of all variables included in the study was performed. This descrip-tive analysis was conducted to assess the signifi-cance in the bivariate analysis among the factors under study and the endpoint used the log-Rank test. The variables that presented p <0.25 at this stage were included in the multiple Cox analysis to determine the factors associated with the EBF duration. The Hazard Ratios (HR) were calculated, as well as their respective 95% confidence interval (95% CI). The variables that presented p <0.05 in the adjusted final model were regarded as a statis-tically significant association. Then, the Kaplan-Constitution and the Consolidation of Labor Laws
(CLT) provides a 120-day paid maternity leave to women, with employment and salary protection 12,13.
From 2008, the Federal Law No. 11,770 started to encourage the extension of maternity leave to 180 days by granting tax incentives to companies that join the program. CLT also provides for two 30-minute breaks for breast-feeding during the working day, until a child reaches 6 months. These breaks don’t replace the regular rest and meal breaks provided to workers. The CLT also states that companies employing at least 30 women aged over 16 must maintain childcare center facilities or have agreements with an external childcare institution13.
Studies have indicated the childcare center in the workplace as a significant element to enable the EBF continuity for six months and breastfeeding (BF) continuity after the end of maternity leave. These studies showed that, even with a strong desire and determination by the mother to breast-feed, without the childcare center and institutional support in the workplace, they wouldn’t have main-tained the BF after the end of maternity leave14,15.
However, studies that associate the return to work with the EBF interruption or early weaning are scarce in the literature.
This study aimed to analyze the factors with respect to the exclusive breastfeeding practice among working women with a childcare center in the workplace, as well as to describe the enjoyment of labor rights.
Method
This is a descriptive study that was developed in a Children’s Coexistence Center (CCI) connected to a Higher Education Institution (HEI) in São Paulo state. This CCI serves 100 children with ages ranging from four months to six years, children of employees, students and residents of the HEI. All employees of this complex are entitled to 120-day maternity leave.
The mother should work at a HEI as inclusion criterion to the child. As one of the aspects to be investigated concerns the enjoyment of labor rights of the breastfeeding mother, the following were excluded from the study: (1) children of students and residents, (2) children whose mothers didn’t work at a HEI and who attended the CCI due to the work relations of their fathers, (3) children
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pacifier use was reported by 63%, and all children required bottle-feeding (Table 1).
In the bivariate analysis between the EBF dura-tion and the factors under study, the variables that presented p <0.25 and were eligible for the multiple analysis were: low weight at birth, health monitor-ing service, mother’s age and age at bottle-feedmonitor-ing introduction (Table 1).
Regarding labor rights, all women reported having been granted a 120-day paid maternity leave and only 10.8% have been granted breastfeeding breaks (Table 2). The two 30-minute breaks pro-vided for in the legislation or the 1-hour reduction in the workload were included in the “breastfeeding breaks” category, according to agreement with the company. Some women reported that they had ag-gregated the workload concerning the breaks as 15 days after the end of the Maternity Leave; however, this situation was not considered as an enjoyment of the breaks right.
The EBF duration of up to six months was related by only 15,2% of the participants. Of all participants, 37% reported not having exclusive breastfeeding at any time. Table 3 describes the average age at the introduction of other liquids. Meier curves were estimated for the significant
variables in the adjusted multiple Cox model. The fundamental ethical principles that guide the research involving humans described and established by Resolution CNS 466/12 and its complementary documents were considered for the development of this research. The project was approved by the Ethics Research Council of the HEI under protocol no. 1,128,554.
Results
Of the 100 questionnaires submitted, four were excluded since these mothers didn’t work at the institution at the time of the birth; five were returned blank; and 45 were not returned even with a new and longer deadline. The questionnaires answered by 46 mothers who met the inclusion criteria were analyzed.
The age of the mothers ranged from 22 to 44 years old and most of them had completed higher education (65.2%). The average age of the children was 2.6 years old, with a predominance of females (63.0%). Approximately 60% of the children en-rolled in the CCI were less than six months old. The
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Table 1. Child- and mother-related data and exclusive breastfeeding duration according to samplecharacteristics, Marília, 2015
Variable Category N % EBF duration p*
P25 Median P75
Child-related data
Gender F 29 63.0 120 150 162 0.9346
M 17 37.0 120 150 180
Low weight Yes 42 91.3 120 150 180
0.2136
No 4 8.7 120 120 120
Type of Delivery Natural birth 1 2.2 - -
-- Cesarean birth 45 97.8 150 150 162
Delivered in a IHAC Yes 10 21.7 6 90 120
0.9923
No 36 78.3 120 150 162
Breastfeeding in the first hour of life
Yes 33 71.7 120 150 180
0.4501
No 13 28.3 120 120 150
Bottle-feeding use Yes 46 100 120 150 162
-Pacifier use Yes 29 63.0 120 150 150
0.3052
No 17 37.0 120 150 180
Introduction to
bottle-feeding 120 days or more 20 43.5 150 150 180 0.0125 Up to 120 days 26 56.5 90 120 150
Introduction to pacifier At birth 6 21.4 120 150 150
0.8028 Up to 15 days 4 14.3 60 90 180 15 days or more 18 64.3 120 150 150 Health monitoring service SUS/UBS 3 6.5 120 120 180 0.1281 Private 40 87.0 120 150 162 Both 3 6.5 90 90 120 Introduction at CCI 6 months or less 27 58.7 120 120 162 0.3308 From 7 to 24 months 18 39.1 150 150 180 24 months or more 1 2.2 - -
-Data related to the mother
Mother’s age <35 22 47.8 120 150 180
0.1149
≥35 24 52.2 105 120 150
Education level Higher education 30 65.2 120 150 180
0.4688 Vocational
education 12 26.1 120 150 180
Medium 4 8.7 90 162 180
Healthcare professional Yes 34 73.9 120 150 150
0.5097
No 12 26.1 120 162 180
Primiparity Yes 28 60.9 120 150 180
0.5251
No 18 38.1 120 150 180
Breastfeeding breaks Yes 5 10.9 90 120 180
0.5148
No 41 89.1 120 150 150
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Table 2. Profile of enjoyment of labor rights by study participants, Marília, 2015 N = 46
Variable N %
Maternity leave
Yes 46 100
No 0 0
Duration of maternity leave
4 months 46 100
6 months 0 0
Breastfeeding breaks
Yes 5 10.8
No 41 89.2
Enjoyment of the breaks right
Two 30-minute breaks 4 8.6
Left 1 hour early 1 2.2
15 days after the end of maternity leave 24 52.2
Did not enjoy 17 37.0
Table 3. Breastfeeding characteristics and reason for BF interruption. Marília, 2015 N=46
Variable N %
Breastfeeding in the first hour of life
Yes 33 71.7 No 13 28.3 Exclusive Breastfeeding No EBF 17 37.0 Up to 3 months 4 8.7 From 3 to 5 months 18 39.1 Up to 6 months 7 15.2 Breastfeeding Up to 6 months 14 30.4 From 7 to 12 months 16 34.8 From 13 to 24 months 16 34.8
Reason for breastfeeding (BF) interruption (N=40*)
Low milk supply 8 20.0
Breast or nipple problems 4 10.0 Difficulties in handle and suction 1 2.5
Mother's return to work 14 35.0
Infant lose interest 18 45.0
Other 10 25.0
Introduction of other liquids at introduction Average age (months)
Tea 32 69.6 4
Water 46 100 4
Juice 46 100 5
Other milk 45 97.8 4
*Excluding mothers who were breastfeeding at the time of the research (n=5) and who didn’t provide the reason for BF interruption (n=1).
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vice or those with both (private and public) healthmonitoring service, as well as children of moth-ers with less than 35 years and those who started bottle-feeding after 120 days of age had greater EBF survival (Figure 1).
Chart 1 shows the risks concerning the EBF interruption (hazard ratio) with a 95% confidence interval of the multiple Cox model. It was observed that children with appropriate weight at birth, those who have a routine private health monitoring
ser-Chart 1. Multiple Cox Model with adjusted HR values and their respective confidence intervals (CI)
for factors associated with EBF duration, Marília, 2015.
Variables Adjusted Hazard Cox Proportional Hazard Ratio
Ratio 95% CI p
Low weight at birth (no) 4.05 1.27-12.88 0.018 Routine monitoring (Private Service) 3.66 1.21-11.00 0.021
Routine monitoring
(Private and Public Service) 20.87 5.84-74.60 0.000 Mother's age (<35) 1.86 1.10-3.14 0.020 Age at bottle-feeding introduction
(after 120 days) 2.41 1.25-4.66 0.009
Figure 1. Survival curves of the EBF duration according to the significant variables estimated by the
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months19. A study conducted in Paraná, in the
southern region of Brazil, with a population of preterm infants, found a median EBF of 63.5 days and only 6.8% continued in EBF at six months of age20. These evidence highlight the importance of
regional research to draft public policies aimed at specific groups and different contexts6,7.
The variables associated with EBF shorter duration in this study were: low weight at birth, public and private health monitoring service at the same time, the mother’s age greater than or equal to 35 years and bottle-feeding introduction after 120 days of life.
Low birth at weight has been appointed as a risk factor for early EBF interruption8,21. This
rela-tionship was also identified by another study, which raised the hypothesis that the lower the weight at birth, the greater the risk of EBF interruption22. A
study conducted in Marília/SP showed that most mothers of premature infants interviewed in out-patient return, 30 days after hospital discharge, reported the mixed breastfeeding practice, due to insecurity regarding weight loss or insufficient weight gain of their children; stress, tiredness and low milk production were among other reasons found for EBF interruption23.
Despite the association found between the EBF shorter duration and the type of health monitoring service provided to the child, it wasn’t corroborated by other studies24. In this study, as the EBF shorter
duration was observed with children with both private and public health monitoring service at the same time, it is possible to infer that this result is due to the different guidance and instructions received by mothers in both contexts. Studies sug-gest that conflicting guidance on the part of health professionals can influence the EBF duration25. In
this sense, a study that compared the EBF indicators focused on the role of the pediatrician with BF-related training and no training, and follow-up by health teams, noted that children monitored by mul-tidisciplinary teams or pediatricians who received BF-related training are more likely to maintain the EBF up to four months of age, compared with children monitored by pediatricians without EBF-related training. Thus corroborating the hypothesis that regardless of the type of health monitoring service of the child, the health professionals train-ing and update to meet the breastfeedtrain-ing demands it is of paramount importance26.
Discussion
This study analyzed the EBF practice among working women with daycare center in the work-place and the factors associated with the EBF duration as well as the enjoyment of labor rights. The study brings to light an incipient, but very present subject in Brazil. The gap between the labor legislation that aims to protect, promote and support breastfeeding and the real enjoyment of these rights by the study participants is highlighted in an unprecedented way, thus reaffirming the importance of a daycare center in the workplace, as well as the need to develop actions carried out both by the companies and by the daycare center, taking into account the factors associated with the EBF shorter duration.
All the participants enjoyed the 120-day ma-ternity leave. This result was already expected in view of the current legislation13. However, it
indi-cates that the institution concerned did not adhere to the important public policy (Federal Law No. 11,770/2008), which extends the maternity leave to six months, corroborating to the EBF duration supported by the MS and the WHO17. In this sense,
according to IRS data, even seven years after the program was launched, only 10.8% of the 174,836 companies in Brazil that could join the program decided to join it.
The breastfeeding breaks right was enjoyed by only a few mothers. Researches suggest that although a daycare center in the workplace has a positive effect on the EBF duration after mater-nity leave,14,15 many women still find it difficult to
breastfeed during working hours14,15. Among the
participants, the vast majority reported that the right was not enjoyed as provided for in article 396 of CLT. This aspect draws attention since the literature has indicated that there may have a sig-nificant relationship with early weaning to when the mother cannot breastfeed the child during the working day or is not able to enjoy the 30-minute break per shift worked18.
The EBF duration of up to six months was rare in the study population (15.2%), however, it was greater than the prevalence found in Brazilian cities. In Fortaleza, in the northeastern region of Brazil, a longitudinal study that included children from low-income families with low weight at birth (<3000 g) found that only 6.0% of the children continued to have exclusive breastfeeding at six
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ConclusionIt was concluded that not all labor rights were enjoyed by the breastfeeding women participants. The proper enjoyment of rights to protect breast-feeding women workers could have had a positive impact on the EBF duration. Low weight at birth, type of healthcare service of health monitoring ser-vice, mother’s age and the age at the bottle-feeding introduction were associated to the EBF duration.
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The results of this study allow a breakthrough in knowledge regarding the exclusive breastfeeding practice among working women with childcare cen-ter in their workplace; however, there is a limitation due to the reduced number of participants and to the high rate of non-response that require caution in the generalization of the results. Researches with larger samples are required in order to corroborate the results found. However, it is worth mentioning that the data presented in this study allow us to reflect on the importance of the proper enjoyment of the labor rights that aim to protect breastfeeding women, especially the breastfeeding breaks.
In this sense, it is possible to raise several con-ditions that, if adopted by companies, can encour-age the working woman to maintain breastfeeding, such as encouraging the proper enjoyment of the breastfeeding breaks right; the extension of the ma-ternity leave, from 120 to 180 days and the creation of breastfeeding support rooms. The adjustments related to the childcare center should also be high-lighted, such as: increasing the number of vacancies to all women working at the company; the creation of a specific and welcoming space so that women can breastfeed; the training of the childcare staff with regard to the handling of human milk and the supply of liquid in the glass instead of the bottle, as well as the pros and cons of using artificial nipples
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